Seamless transition from hospital to home

Program providing discharged patients with access to services to help manage their chronic conditions at home

Jean Brown says Niagara Health’s Integrated Comprehensive Care (ICC) program has changed her life. In December 2016, the 73-year-old grandmother was recovering from a heart attack when she started having trouble breathing.

Ms. Brown received care in the Emergency Department at Niagara Health’s Welland Site, where she was then connected with an Integrated Care Co-ordinator after it was determined she met the criteria for the ICC program.

Launched last April, the program directly integrates hospital and community care services for patients who are admitted with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) and require home care after discharge.

Ms. Brown no longer drives and has limited ability to travel.

“So when they said the healthcare workers would come to the house, I said this is wonderful.”

Ms. Brown was discharged from Niagara Health’s Welland Site on a Friday. By 9 a.m. Saturday, a nurse was knocking at her front door to deliver care.

“I was so happy to see her the next day because I was scared,” says Ms. Brown. “She took my blood pressure and she explained a lot of things and explained what happened to me.”

Heather Paterson, Niagara Health Director of Patient Care and Integrated Comprehensive Care project lead, says as of the end of 2016, 311 patients have come through the ICC program.

Integrated Care co-ordinators act as a link between hospital specialists and connects COPD and CHF patients with necessary service providers in the community, including home care provided by St. Joseph’s Home Care.

“The feedback from our patient satisfaction surveys has been very positive,” says Ms. Paterson. “So far the data is indicating that we’ve created significant positive change.”

Patients and their family members have access to support on a 24/7 basis for 60 days after discharge. For Ms. Brown, that means she receives home visits from nurses, physiotherapists and a dietitian.

“I learned a lot from this program. The dietitian came to my house and showed me how to read labels,” says Ms. Brown. “I honestly believe if I would have had this program after my first heart attack, I don’t think I would have had the heart attack in December because I think I would have understood what was happening. The nurses really explained it to me and explained what I have to do.”

For those patients who are readmitted, Ms. Paterson says they are staying in hospital for shorter periods of time because they are learning to manage their chronic conditions.

“It’s making the transition from hospital to home a more seamless one,” says Ms. Paterson.

The ICC program builds on the success of St. Joseph’s Health System’s early work in launching an innovative approach to integrated care and currently includes all acute care hospitals in the Hamilton Niagara Haldimand Brant LHIN.